It can be really difficult for us to hear bad news, especially when the bad news is about something serious like our health.
In some of our recent research about the conversation between doctors and patients with chronic conditions, we asked patients to share how their doctor communicated the diagnosis to them, and how they as the patient felt hearing the news.
We found that, even though patients are often upset when finding out they have a condition like Multiple Sclerosis, there are things that the doctor does or doesn’t do that can positively or negatively impact the patient moving forward.
First, we found that patients want and need the whole truth about their condition. Doctors may sometimes think they’re helping by watering down the information or not talking too much about details of the condition, when in reality the patients need this information to gain clarity, familiarity, and to successfully move forward to starting treatment.
We also found that, while it’s very important for the doctors to give the patients a detailed and complete diagnosis, doctors should also make sure to leave enough time during the conversation to talk about treatment options. If the patient hears just that they’ve been diagnosed with Leukemia but doesn’t hear what treatment options are available, they could be left without much confidence or hope in being able to treat their condition.
Lastly, we found that the first few sentences of the conversation communicating bad news, like a diagnosis, matter a lot. In several instances patients described how the doctor didn’t communicate the beginning of the diagnosis well, saying things like “you have an aggressive cancer” or “I’m so sorry”. In these cases, the patient tended to not hear and really process the rest of the conversation. Things like poor word choice or the wrong demeanor can impact patients negatively in a way that lasts far beyond the diagnosis.
No patient wants to hear bad news. But when bad news needs to be communicated, it helps the patient immensely when they hear the whole truth, all about their treatment options, and are met with words and demeanor that give them as much confidence and hope as possible.(Read full post)
Imagine you’re in the shoes of Bill, a type 2 diabetes patient. You’ve just left the doctor’s office, where you’ve told your PCP that things seem to be going pretty well. You are eating better, you are starting to take some short walks, and overall you feel pretty good. Your doctor seems happy about all of this, but your A1c is higher than he’d like, he tells you. He says you should pay more attention to things like carbs, and creating a balanced plate at meals. And you should exercise more, because the walks aren’t doing the trick.
What? You just told him that you’re eating well and you’re exercising. You feel let down as you leave the appointment. On your way out, the receptionist hands you a few pamphlets that your doctor wants you to take home and read.
You scan the titles: Eating Healthy with Diabetes, The Diabetes Diet, and Type 2 Diabetes and Exercise. You toss the pamphlets in the trash on your way to your car.
What just happened here? The short version is this: Bill goes to his quarterly appointment feeling energized and proud of the work he’s done caring for his diabetes, only to be told that what he’s doing isn’t enough, and he needs to do more to get tighter control of his numbers. His doctor hasn’t truly heard him, and is treating him like a number. On top of that, his provider gives him information-heavy, generic materials covering topics Bill already thought he was managing well. Bill leaves feeling defeated and annoyed with his doctor.
These well-intentioned informational materials typically get tossed aside for these reasons and others. In the research we’ve conducted with patients with chronic diseases, they’ve told us the number one quality they value in their doctors is their ability to listen. They want a doctor to hear their view point and take their position into consideration when coming up with an action plan. Patients want a management plan that reflects both their expertise (as the patient) and the doctor’s expertise. The complete opposite happened to Bill.
There are so many ways Bill’s scenario could be improved. Key tactics that could have a big impact on Bill’s situation include:
- Point of care tools delivered to his PCP to help him work with Bill to uncover his key behavioral drivers to change
- Trainings to help his PCP communicate more effectively and utilize appointment time more efficiently
- Behaviorally-based content provided to Bill to help him set personal goals that are of interest to him and that will help him work through his unique problems and obstacles
These kinds of personalized solutions allow us to reach an audience more effectively and promote positive change. They help facilitate better in-office communication between doctors and patients, which impacts how a patient views his or her condition and ultimately how it gets managed. And these solutions serve as extensions of the appointment, helping patients manage their conditions over the 3 or 4 months they are on their own between appointments.
It’s time to rethink how we’re educating our patients and truly begin energizing them to take an active role in their care.(Read full post)
Last week our behavioral and creative teams had the privilege of receiving a 1-day health coach training from experts at the UNC-Greensboro Department of Public Health Education. This training was a unique opportunity to learn best practices when working with patients in the most intimate of settings: a health coaching session.
The dynamic day included an explanation of the 3 different styles of communication used in coaching: Directing, Guiding, and Following.
“Directing” takes place when the coach tells the patient what to do and the best way to do it. “Following”, on the other hand, has the coach openly listening with no agenda, and following along with whatever the patient wants to discuss. The “Guiding” style is when the coach affirms that the patient is capable, and works to increase the patient’s ability to change the desired behavior, guiding them through questions and conclusions rather than dictating them.
It was interesting to learn from this training that, though guiding may be favored in our changing healthcare environment, there is a time and place for each of the 3 styles of communication in talking with patients. There are times when, for the patient to understand the gravity of a diagnosis or necessity of treatment, the doctor should use the directive communication style. The patient needs to know exactly what to do and how important it is to do it. Other times following may be most appropriate, if the patient simply needs time to have their thoughts or concerns heard.
A big part of my internship with MicroMass this summer is working on a research project that looks at the trends in doctor/patient communication and how the way in which a doctor communicates with the patient may bring about different patient outcomes. We’re currently fielding the study, and are eager to learn more about the doctor/patient relationship from people living with chronic disease. Of particular interest is learning how these different coaching styles are being used in real-world situations and how they may impact both positive and negative outcomes.
The question is –which style is most beneficial when? And how can the healthcare provider figure that out in at any given moment? We are looking forward to seeing how the results of this study bring us one step closer to finding out.(Read full post)
Patient engagement is a concept that we’ve been hearing a lot about for the last couple of years and one that is critical to impacting health outcomes. As we’ve seen in our own research, oftentimes industry terms are considered buzzwords and carry different meanings to different people. While there isn’t true consensus on the exact definition, even greater uncertainty for me remains around the steps required to actually create an engaged patient.
Type “patient engagement” in Google, and you get 754,000 results. There are sites that claim they’ll help you boost patient engagement, help you create motivated and engaged patients, and even provide tools to help healthcare providers better understand why patient engagement is so important. Clearly, it’s an important topic, but who do you listen to when it comes to motivating patients? What is truly important?
I watch a lot of TED Talks, and one that sticks out in my mind was presented by e-Patient Dave. Dave was diagnosed with terminal cancer, but through networking and social media, was able to find a treatment that ultimately saved his life. He has a website that contains his own postings, guest entries, and other resources from the patient and HCP perspective.
In March, Dave shared a guest post, written by Dr. Patricia Flatley Brennan, that talked about the importance of technology in creating an engaged patient. I agree, technology allows for so many different experiences for patients and providers that were not available just a handful of years ago. But when I read the title, Patients+Providers+Technology=Engagement, the first thing I thought was, “It’s not this simple.” Questions and thoughts were popping into my head, like:
- What if patients have inaccurate perceptions about their condition?
- What if the provider uses terms that the patient doesn’t understand?
- What if the technology is just information overload?
- Technology alone isn’t the answer
Dr. Brennan makes some really good points. For example, she talks about the fact that patients are truly the experts when it comes to their own bodies. She also talks about the importance of patient-provider communication. But she goes on to state “the key to…creating successful partnerships between patients and providers is technology.” As a behavioral science expert, this made me nervous. We don’t want to be sending the message that if technology is included, patients will be more engaged. As I stated earlier, it’s just not this simple.
Take physical activity trackers, for example. Lots of people use them to track their daily activity. They may even bring their trackers to doctor’s appointments. But these trackers are nothing more than a digital way to track activity. For patients who are also struggling with things like not knowing how to exercise, not knowing what exercises to do, not knowing what equipment they need, or believing they need to lose 50 pounds for it to matter, a tracker, while digital, isn’t going to help them with these underlying issues. As a result, they are no more engaged before or after using the tracker.
I don’t dispute the value of any of the programs that are presented in the posting. In fact, many of them look really great, and deserve attention for the positive change they’ve helped create. What I am cautioning against more generally is promoting technology alone as the key ingredient. While technology is important, paying attention to the underlying drivers of behavior is equally critical in promoting change. Starting with an understanding of what drives behavior, then integrating this with technology, can yield powerful tools that will not only change patient behavior but also impact health care delivery and clinical outcomes.
I’m not in any way downplaying the role of technology here, but suggesting that taking into account the drivers of behavior can lead to even more meaningful technological developments.(Read full post)
Take Two Apps and Call Me in the Morning
It may not be too long in our future when part of a prescription from our physicians may include and app (or two). This is the exciting idea of medically prescribed apps. Some futurists predict that doctors will prescribe FDA-approved apps to treat patients. So far, the FDA has maintained that it will only vet apps that perform device-like functions, such as making diagnostic determinations or treating ailments. The FDA has yet to release its full guidance on the regulation of mobile apps and will not go after the many available downloads that make untested medicinal claims until its rules are in place.
WellDoc is one of the pioneers in the prescription-app field. Its DiabetesManager system collects biometrics about a patient’s diet, blood sugar levels and medication regimen through manual input or from wireless devices. It then gives advice to a patient and sends clinical recommendations to the doctor. The Food and Drug Administration gave the system 510(k) clearance to operate as a medical device in 2010.
Happtique (health app boutique) is a company that operates a mobile app prescribing solution for healthcare called mRx. Happtique has recently launched a pilot that will test whether the company’s solution will encourage doctors to prescribe mobile software for patient use. mRx consists of Apple and Android smartphone and tablet compatible apps that focus on cardiology, rheumatology, endocrinology, orthopaedics, physical therapy and fitness training. The mRX system gives patients more structured guidance when it comes to selecting and using health apps and empowers them with tools to help them take a more active role in their care. And similar to traditional prescription, mRx will track how many times an app is prescribed as well as how many times patients click the “fill” button once the prescription is sent.
If the mRx trial is successful, it will help demonstrate that mHealth technology will be viewed as legitimate, powerful healthcare tools, not just fun programs to install on a phone or tablet.
From a behavioral point of view, the WellDoc and mRx systems can help encourage a dialogue between physicians and patients about available healthcare technology tools. These conversations will not only give patients additional resources, but will also encourage them to consider incorporating apps and other healthcare technology into their health management. In addition to increased health care provider connectedness, these systems also help achieve behavioral change and continued adherence through sustained influence over the patient’s multiple chronic states and enhanced patient self-determination.
When you think about it, these apps are no different from physicians prescribing a diet, a support group or any other resource. In fact, these apps will enable physicians to be more creative with the ways they engage their patients and provide the best care to them.(Read full post)
I am always pleased to hear that some industries are creating jobs. A recent report from Georgetown says: “Between 2010 and 2020, healthcare occupations will increase from 10.1 million to 13.1 million jobs. From 2010 to 2020, healthcare production will increase by over 70 percent, from $1.8 trillion to $3.1 trillion. In the same period, there will be an estimated 5.6 million healthcare job vacancies.” In essence, Georgetown researchers are forecasting that the number of jobs will grow nearly 30 percent (adding in “replacement jobs,” those left open by retirements, deaths and resignations).
However, the study also indicates that 82% of the expected influx of jobs will require post-secondary education and training. This statement tells me that figuring out the healthcare system is going to become even more complex. This makes sense when you consider that all the new health-related technologies that (among other things) are requiring the increase in education from our healthcare workers. This made me shudder at the thought of getting sick, because I am not sure I will be smart enough to navigate this brave new world.
But then I read a recent article about a specific healthcare position called a “navigator”. In general the role of a navigator is to be a liaison among patients, particularly cancer patients, and their many doctors and other medical and related professionals. In other words, navigators help people through chronic disease management.
There are two kinds of navigators: one is a patient navigator and the other a nurse navigator. They sound similar; however, they are distinct. Patient navigators can be lay people or social workers whereas nurse navigators are registered nurses, usually with a bachelor’s degree.
Navigators are particularly helpful during cancer treatment because patients don’t always know what they need as part of disease management and survivorship. The navigators constantly assess a patient’s needs, which can be medical, such as follow-up exams and diagnostic testing, or peripheral facets, such as overall health and wellness moving forward. That could include nutrition counseling or the seeing a mental health professional.
Navigators, whether patient, nurse or some other derivative role is likely to grow substantially because there’s a need to coordinate care across so many settings. That makes me feel a little better with all the changes in healthcare coming my way. This seems like a role that may expand into other (non-cancer) areas. If this is true, then getting sick will be a little less scary as there will be someone to guide me through it all.(Read full post)
If you’re like me, you’ve heard the song hundreds or even thousands of times and never thought too deeply about the lyrics. Let’s face it; they don’t make a lot of sense on their own. Some have speculated that the song references the personalities of different members of the band (i.e. “one holy roller” for George Harrison, the “spiritual” Beatle). Or possibly, it’s just the result of some other illegal, “creative influences.”
As I’ve been researching journal articles and reading blogs and editorials on healthcare reform, I’ve been struck by the fact that so many of the proposed changes to the system are about making healthcare more collaborative. It’s about providers, patients, and other stakeholders coming together. Just take a look at three of the proposed changes—Accountable Care Organizations (ACOs), Insurance Exchanges, and Patient-Centered Medical Homes (PCMHs).
Accountable Care Organizations
ACOs are one of the most anticipated aspects outlined in healthcare reform. The idea is that all sorts of providers, including physicians, specialists, and hospitals will come together to provide care that focuses on quality rather than volume of services. Kind of sounds like an HMO, right? Well, not exactly. One of the major differences between ACOs and HMOs is that ACOs give their patients the option of going to providers outside the ACO network. ACOs would cover a minimum of 5,000 Medicare patients for at least 3 years. The goal of an ACO is for providers to work together to cut unnecessary healthcare costs while still providing quality services. If they are able to meet certain cost and performance measures, they’ll be reimbursed by Medicare according to their cost savings. To keep ACOs from dominating the marketplace, they’ll be subject to anti-trust and anti-fraud review processes. The moral of the story is that it’s advantageous to work as a team to save money and be reimbursed a chunk of the savings.
What happens to all the people who aren’t insured through their employer or are purchasing their own insurance? Prior to healthcare reform, those individuals would either end up paying higher premiums or choosing to forego insurance entirely. If the individual mandate stands, anywhere from 30-35 million people who were previously uninsured will be required to purchase insurance. With so many people buying insurance on their own, why not bring them together to leverage more affordable premiums? That’s exactly what insurance exchanges are designed to do. Exchanges will prohibit insurance discrimination against individuals with pre-existing conditions and bring together individuals and small businesses (with fewer than 100 employees) to purchase insurance. All exchanges will be required to have four different benefit categories of plans as well as a catastrophic plan. These exchanges will be run by states and are effective starting January 1, 2014. For more information on exchanges, see the Kaiser summary of healthcare reform.
Patient-Centered Medical Homes
In a similar vein to ACOs, PCMHs will bring together providers to enhance patient primary care. The difference between an ACO and a medical home is that ACOs are networks of providers, while a medical home is a team of primary care providers, usually made up of physicians, nurses, and physician assistants, who are assigned to a particular patient. The PCMH team is led by the patient’s personal clinician who works together with their team to coordinate care and promote overall patient health. This approach has been shown to be especially beneficial for patients with chronic conditions, but is also an effective approach for other groups of patients, as well. The Affordable Care Act provides an incentive for PCMHs—they can receive reimbursement for caring for patients with chronic conditions who are covered by Medicaid.
Even though the lyrics of “Come Together” may not make all that much sense, the message certainly applies to the changes we’re seeing in healthcare today. Healthcare is moving in the direction of collaboration and it’s moving quickly. Most of the changes mentioned above are already being implemented or in the final stages of planning. Only time will tell how these changes actually stand up to all the hype, but for now, it looks like the one thing is for sure–patients, providers, and others are coming together, right now, over the health concerns of you and me.(Read full post)
The tablets I am talking about are not the drug kind but iPads and other mobile devices. It is clear that physicians are adopting the use of tablet devices in their practice, and they seem to be using them more and more every day. This Technology Review video helps explain why physicians gravitate to these small, mobile devices. In essence, tablets allow physicians to bring real-time, accurate data right to the patient’s bedside – fast, easy and convenient.
However…my real story is how the medical schools are adopting tablet technology to change educational and training methods and ultimately practice methods.
Recently, each member of the incoming class of 2015 of Irvine’s School of Medicine received an iPad as part of its initiative to provide students with a digital medical education. And this was the second year Irvine has done this. The iPad is a core component of the school’s innovative iMedEd Initiative, which officials say has grown into one of the most comprehensive, fully digital medical education programs in the country.
Include Yale’s School of Medicine with the growing list of medical schools that are embracing the iPad as a primary source of medical teaching. This upcoming year, Yale will be giving an iPad 2 to all 520 of their medical students. iPad 2s will provide professors with new classroom tools, including clearer graphics and the ability to change course materials as often as necessary.
According to mobihealthnews.com, the following nine schools have embraced tablet-based teaching: Brown Alpert Medical School, Georgetown University School of Medicine, Ohio State College of Medicine, Stanford School of Medicine, UCLA School of Nursing, University of California Irvine School of Medicine, University of Central Florida College of Medicine, and University of Minnesota Medical School.
What this all means is that while the iPad, specifically the iPad 2, is not quite a game-changer in and of itself (at least anymore), it certainly has accelerated trends in healthcare education and training that were developing – or should I say were inevitable.(Read full post)
You’ve heard us say this before: adherence to medication is a problem. You’ve heard us say this before too: improving adherence is not as simple as reminding people to take their medicines and giving them co-pay assistance.
Those who undertake the development of adherence programs should be prepared to invest considerable effort and resources. In the face of expiring patents and new drugs entering the market, it’s no surprise that companies focus on acquisition and conversion rather than on keeping patients on existing drugs… until you get the numbers.
“A new report conducted by the New England Healthcare Institute (NEHI) found that not taking medications as prescribed leads to poorer health, more frequent hospitalization, a higher risk of death and as much as $290 billion annually in increased medical costs. Anywhere from one-third to one-half of patients in the U.S. do not take their medications as instructed.”
Bottom line, we all need to do better when it comes to adherence: Patients need to do better, doctors need to do better, pharmacists need to do better, and pharma companies need to do better. A co-worker and I recently discussed his issues with adherence over a company lunch. A lunch at MicroMass, a company that develops adherence programs! Adherence is hard for all of us.
Or at least that’s how we feel now. Here at MicroMass, we are beginning a systematic analysis of branded adherence programs for the management of chronic conditions. We anticipate seeing a lot of the reminder+savings card packages we’ve criticized, maybe a few partially behaviorally-based programs, and a sprinkle of the customized, comprehensive, easy-to-use gold-standard programs we strive for. Stay tuned for a white paper detailing the best practices for patient adherence and the nitty-gritty on what’s out there.(Read full post)
Technology advancement surrounds us. GPS, iPhones, you name it – it’s so expected that it’s become a part of our everyday lives. Science and medical advancements are no different. There are new devices, procedures and therapies surfacing every day.
I, for one, appreciate and take advantage of these technology advancements on a daily basis and I also take comfort knowing that should my health decline, there is hope, given the wealth of expertise within driving distance from my home.
But as I was reading a few recent articles related to patient-physician communication, I have to wonder – have we lost touch with the fundamentals of human touch and care? I am not trying to point fingers at physicians and their poor communication skills anymore than I am pointing fingers at patients who often don’t take the initiative to ask the right questions or try to act as partners in their care. Yes, I do believe that there is a lack of decent communication skills, but what I really question is that fact that as a society we don’t seem to value in-person communication skills, at least they way that maybe we once did.
Communication can be powerful. I don’t think anyone would argue that point. But did you know that communication can be healing?
A recent patient-physician communication study by Robins, et al. demonstrated the benefits of transparency. When physicians were more transparent and took the time to explain their actions during physical exams as well as their reasoning behind clinical decisions – this promoted greater patient understanding and collaboration. Other studies examining physician transparency in communicating have illustrated outcomes such as greater patient adherence, reduced uncertainty and symptom relief. If improved health outcomes are not enough, some research has also demonstrated that patients were less likely to sue their physicians if they felt that they had received adequate information and advice.
The art of listening is just not an abundant trait anymore, especially in medical encounters. A recent commentary in JAMA by Dr. Wendy Levinson and Dr. Philip Pizzo (both affiliated with the University of Toronto) states that “excellent medical care combines sophistication in scientific knowledge with equally sophisticated communication skills to understand the needs of the individual patient.” The authors go on to cite the many barriers to effective physician communication skills such as reduced time and increased volume of patients, handoffs between physicians, and lack of communication training in residency programs. No different than many of us, physicians are under intense pressure to be productive and that productivity is most often associated with number of patients seen.
In the US, an estimated 30-40% of physicians are experiencing burnout. And burnout leads to reduced empathy, greater dissatisfaction, and reduced patient adherence.
A major shift needs to occur. I think as patients and consumers, we need to expect and demand that physicians communicate with us in a way that is respectful and that allows us to be as collaborative as possible. But a major shift at a higher level will also be required – laws, processes and infrastructures that assign value to communication – that financially reward physicians who incorporate positive communication skills – and greater emphasis at the research and medical school faculty level. I hope that I witness this advancement during my lifetime.(Read full post)